摘要:

Objective:The purpose of this study was to compare the impact of trauma patient outcomes before and after Level II American College of Surgeons (ACS) verification was received in a not‐for‐profit community hospital.Methods:This was a retrospective analysis of hospital discharge data for timeframes before and after Level II ACS verification was conducted. Originally, 8,674 patients were identified using theInternational Classification of Diseases, 9th Revisioncodes for trauma. These data were parsed to 7,811 patients by usingInternational Classification of Diseases, 9th Revisioncodes 800xx through 959.9x, which signify an admitting diagnosis of trauma; 3,835 of the patients were admitted after the July 28, 1998, verification date. Blunt injuries constituted the vast majority of the patients (n = 7,488). Outcome measures studied included changes in length of stay (LOS), mortality, and total cost. Internal control was coronary artery bypass graft patients at the same hospital, and external control was trauma patients at a non‐ACS hospital over the same time period. Data are presented withpvalues and SE and the ratio of observed/expected values on the basis of the allpayer severity‐adjusted diagnosis‐related group severity model.Results:The two timeframes exhibited statistically different outcomes in several variables. Adjusting for severity postverification, LOS was 10% less (p< 0.000). Similarly, severity‐adjusted mortality observed/expected ratios were significantly different: 0.81 before versus 0.59 after (p< 0.000). The severity‐adjusted ratio of costs found that the postverification era was 5% lower (p< 0.000). The contribution margin of the trauma patient population to the hospital well exceeded any postverification costs. Both control groups exhibited no significant changes in their severity‐adjusted outcomes, which could have invalidated these results.Conclusion:This study suggests that the efforts and resources consumed achieving ACS Level II trauma center verification appear to result in desired outcomes as evidenced by decreased LOS, reduced in‐hospital mortality rates, reduced cost, and improved contribution margins.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background:A study was performed to demonstrate that slower respiratory rates (RRs) of positive‐pressure ventilation can preserve adequate oxygenation and acid‐base status in hemorrhagic states, whereas “normal” or higher RRs worsen hemodynamics.Methods:Eight swine (ventilated with 12 mL/kg tidal volume, 0.28 FIO2; RR of 12 breaths/min) were hemorrhaged to < 65 mm Hg systolic arterial blood pressure (SABP). RRs were then sequentially changed every 10 minutes to 6, 20, 30, and 6 breaths/min.Results:With RRs at 6 breaths/min, the animals maintained pH > 7.25/SaO2> 99%, but increased mean SABP (from 65 to 84 mm Hg;p< 0.05), time‐averaged coronary perfusion pressure (CPP) (from 50 ± 2 to 60 ± 4 mm Hg;p< 0.05), and cardiac output (Qt) (from 2.4 to 2.8 L/min;p< 0.05). With RRs of 20 and 30 breaths/min, SABP (73 and 66 mm Hg), CPP (47 ± 3 and 42 ± 4 mm Hg), and Qt (2.5 and 2.4 L/min) decreased, as did PaO2and PaCO2(< 30 mm Hg), withp< 0.05 for each comparison, respectively. When RR returned to 6 breaths/min, SABP (95 mm Hg), CPP (71 ± 6 mm Hg), and Qt (3.0 L/min) improved significantly (p< 0.05).Conclusion:After even moderate levels of hemorrhage in animals, positivepressure ventilation with “normal” or higher RRs can impair hemodynamics. Hemodynamics can be improved with lower RRs while still maintaining adequate oxygenation and ventilation.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objective:The purpose of this study was to determine the magnitude and duration of pain and disability in patients with rib fractures treated using current standard therapy. This was a prospective case series.Methods:Injured patients with a chest radiographic diagnosis of one or more rib fractures between June 1, 2001, and October 31, 2001, were asked to participate. Pain levels were assessed at days 1, 5, 30, and 120 after injury using a visual pain scale (0‐10). Disability at 30 days was assessed using the SF‐36 Health Status Survey, and the total number of days lost from work/usual activity was recorded at day 120. The setting was a university‐based Level I trauma center.Results:Forty patients with a mean of 2.7 ± 1.6 rib fractures were enrolled. Twenty‐three patients had isolated rib fractures and 17 patients had associated extrathoracic injuries. Mean rib fracture pain was 3.5 ± 2.1 at 30 days and 1.0 ± 1.4 at 120 days. For patients with associated extrathoracic injuries, rib pain was equivalent to pain in the rest of the body at all intervals. When compared with the chronically ill reference population of the RAND Medical Outcomes Study, our patients as a group were more disabled at 30 days (p< 0.001) in all categories except emotional stability, where they showed equivalent disability, and in their perception of general health, where they were significantly less disabled (p< 0.001). The total mean days lost from work/usual activity was 70 ± 41. Patients with isolated rib fractures went back to work/usual activity at a mean of 51 ± 39 days compared with 91 ± 33 days in patients with associated extrathoracic injuries (p< 0.01).Conclusion:Rib fractures are a significant cause of pain and disability in patients with isolated thoracic injury and in patients with associated extrathoracic injuries. Developing new therapies to accelerate pain relief and healing would substantially improve the outcome of patients with rib fractures.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background:Resuscitation fluids can have variable effects on key functions of circulating polymorphonuclear neutrophils (PMNs) such as oxidative burst, chemotaxis, and bacterial killing. We hypothesized that choice of resuscitation fluids will also affect the rate of PMN apoptosis. To test this, we studied cellular death (apoptosis and necrosis) in human PMNs after brief exposure to different hypertonic and isotonic fluids.Methods:Blood from 12 volunteers was incubated for 1 hour at 37°C in normal saline, 6.0% dextran‐70, 7.5% hypertonic saline, and 7.5% hypertonic saline with 6% dextran‐70. Isolated PMNs were double labeled with fluorescein‐Annexin V and propidium iodide, and apoptosis and necrosis were measured using flow cytometry. Caspase activation was also detected with flow cytometry using pancaspase inhibitor (carbobenzoxy‐valyl‐alanyl‐aspartyl‐fluoromethylketone) in nonisolated whole blood samples to determine apoptosis. Finally, cDNA macroarrays were used to evaluate the expression of 23 genes involved in the regulation of cell cycling and apoptosis.Results:Exposure to hypertonic fluids (hypertonic saline and 7.5% hypertonic saline with 6% dextran‐70) significantly (p< 0.05) increased necrosis in isolated PMNs. In whole blood samples, PMNs exposed to dextran demonstrated significant apoptosis as evidenced by increased caspase activation. Dextran was the only fluid that affected leukocyte gene expression, inducing significant up‐regulation ofRbgene transcription.Conclusion:Hypertonic fluids and dextran decrease human polymorphonuclear cell survival through necrotic and apoptotic pathways, respectively.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background:Techniques for better hemorrhage control after injury could change outcome. A large‐animal model of lethal, uncontrolled hemorrhage was developed to test whether the use of various hemostatic agents would decrease bleeding and improve early survival.Methods:A complex groin injury was created in 30 Yorkshire swine (42‐55 kg) to produce uncontrolled hemorrhage. This injury included semitransection of the proximal thigh and complete division of the femoral artery and vein. After 5 minutes, the animals were randomized to (n = 6 animals per group) no dressing (ND), standard dressing (SD), SD and Rapid Deployment Hemostat (RDH) bandage, SD and QuikClot hemostatic agent (QC), or SD and TraumaDEX (TDEX). Limited volume 0.9% saline (1,000 mL over 30 minutes) resuscitation was started 30 minutes after injury. We measured blood loss, early mortality (180 minutes), and physiologic markers of hemorrhagic shock (e.g., cardiac output, blood pressure, hemoglobin, metabolic acidosis).Results:Application of wound dressing decreased mortality in all groups compared with the ND group (83% mortality). However, this difference was significant (p< 0.05) only for the QuikClot hemostatic agent (0% mortality). Before the application of dressing (first 5 minutes), there were no differences in blood loss between the groups. After application of dressings, the QC group had the lowest blood loss (4.4 ± 1.4 mL/kg).Conclusion:Of the hemostatic agents tested, QuikClot improved survival and decreased bleeding in a swine model of lethal vascular and soft tissue injury.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background:Management of the open abdomen in trauma and nontrauma patients is difficult, and some areas of controversy remain. Gastrointestinal fistulas are serious complications that are associated with significant mortality. We present our method for management of patients with open abdomen and also present a logical technique of subsequent repair of the late giant ventral hernias that uniformly occur in these patients.Methods:From January 1992 to December 2001, nine patients with open abdomen underwent successful immediate closure with bilateral bipedicle anterior abdominal skin flaps. The major points of this technique of abdominal closure are coverage of abdominal viscera with absorbable mesh and mobilization of the skin and subcutaneous tissue on both sides of the abdominal wound to cover the absorbable mesh. All patients had uneventful recovery and also had subsequent late giant ventral hernias. Repair of the late giant ventral hernias was performed several months later by inserting a large sheet of nonabsorbable mesh under the rectus abdominis muscles that form the neck of the ventral hernia bilaterally. This technique of ventral hernia repair is also called retrorectus prosthetic mesh repair.Results:Five men and four women were entered into the study. The age ranged from 22 to 53 years (median, 35 years). Seven patients suffered from blunt and penetrating trauma and two patients suffered from nontrauma causes. All patients with immediate closure of the open abdomen had uneventful recovery. Late giant ventral hernias (diameter, > 10 cm) occurred in all patients. The time from closure of the open abdomen to subsequent repair of the giant ventral hernias ranged from 7 to 48 months (median, 14 months). Follow‐up after hernia repair ranged from 1 to 72 months (median, 9 months), and we have seen no evidence of recurrence.Conclusion:Immediate closure of the open abdomen with bilateral bipedicle anterior abdominal skin flaps is an effective technique for dealing with such potentially complicated problems. Management of late giant ventral hernias with retrorectus prosthetic mesh repair is theoretically reasonable and, so far, no recurrence has been observed in our patients.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background:The pattern and severity of crash injury depends on a complex interaction of biomechanical factors such as deceleration velocity at impact (delta‐V), seat‐belt and airbag use, and type of impact. Human body characteristics such as height and weight may play an important role. We hypothesized that body mass index (BMI) will influence crash injury patterns.Methods:The University of Michigan Program for Injury Research and Education database was queried. Three cohorts were analyzed, lean (BMI ≤ 25 kg/m2), overweight (BMI 25‐30 kg/m2), and obese (BMI > 30 kg/m2)Results:There were 189 detailed crash cases, with 22 fatalities. There was an increased risk of fatal outcome associated with the obese cohort (adjusted odds ratio, 4.2 compared with lean;p= 0.04). Age, delta‐V, seat‐belt use, and type of impact were independent predictors of Injury Severity Score (ISS). After adjusting for other modifiers, being overweight was associated with decreased ISS (p= 0.03) and abdominal maximal Abbreviated Injury Scale (mAIS) score (p= 0.008) when compared with the lean cohort. However, the lower extremity mAIS score increased when overweight (p= 0.03) and obese cohorts (p= 0.001) were compared with the lean cohort.Conclusion:Although no difference in ISS was identified between the lean and obese cohorts, there was an increase in mortality with the obese cohort. The severity of lower extremity injuries increased with increasing BMI. The overweight cohort was associated with lower ISS and abdominal mAIS score compared with the lean cohort. This protection may be attributable to an increase in insulating tissue, or a “cushion effect,” without a significant increase in mass and momentum.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background:Injury patterns among children in frontal collisions have been well documented, but little information exists regarding injuries to children in side impact collisions.Methods:Restrained children 14 years old or younger admitted to the hospital for crash injuries were analyzed. Data concerning injuries, medical treatment, and outcome were correlated with crash data. Case reviews achieved consensus regarding injury contact points. Side impacts were compared with frontal impacts. These results were then compared with data from the National Automotive Sampling System.Results:There were no differences between the groups with respect to age, sex, restraint type, or seat position. Compared with frontal crashes, children in side impacts were more likely to have an Injury Severity Score > 15 (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.7‐5.8) and were more likely to have Abbreviated Injury Scale score 2+ injuries to the head (OR, 2.5; 95% CI, 1.4‐4.4), chest (OR, 4.0; 95% CI, 2.0‐8.0), and cervical spine (OR, 3.7; 95% CI, 1.2‐11.3). When compared with National Automotive Sampling System data, similar trends were seen regarding Abbreviated Injury Scale score 2+ injuries to the head, chest, and extremities.Conclusion:In this study population, side impacts resulted in more injuries to the head, cervical spine, and chest. Knowledge of this pattern—the side impact syndrome —can help guide diagnosis, treatment, and prevention strategy.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background:We reviewed the incidence and injury severity of children with gunshot wounds (GSWs) at our hospital.Methods:We compared trauma registry, emergency unit (EU), and admissions data from January 1993 to June 1996 (period I) and July 1996 to December 1999 (period II). Outcome measures included EU disposition (death, immediate operation, pediatric intensive care unit, ward), injury severity, mortality, and injury cause (accidental, intentional).Results:We treated 437 children for GSWs in the EU, with 238 (54%) admissions and 199 discharges. Comparing period I versus period II, patients treated declined from 288 to 149 (−52%,p< 0.001), and admissions decreased from 159 to 79 (−50%,p< 0.001). Injury severity increased from 35% to 57% (p< 0.001). Patients requiring immediate operations increased from 20% to 42% (p< 0.001). Direct ward admissions declined from 65% to 43% (p< 0.001). Deaths occurred in 3% of patients in both time periods. Accidental and intentional GSWs were evenly divided.Conclusion:An alarming number of children, an average of 62 children annually, were treated for GSWs at our hospital. Despite a 52% reduction in GSWs, the percentage of severely injured patients increased by 63%. These data emphasize the importance of prevention, education, early assessment, and operative treatment.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background:Rib fractures have a strong association with nonaccidental trauma (NAT) and severe trauma. The purposes of this study were to evaluate rib fractures in children to determine (1) the positive predictive value of a rib fracture in defining NAT and (2) the frequency of rib fractures as the only skeletal manifestation of NAT.Methods:We reviewed the medical records and imaging of all children with rib fractures over a 6‐year period. NAT was determined by the Child Advocacy and Protection team.Results:In children younger than 3 years of age, the positive predictive value (PPV) of a rib fracture as an indicator of NAT was 95%. The positive predictive value increased to 100% once historical and clinical circumstance excluded all other causes for rib fractures.Conclusion:In this study, rib fracture(s) were the only skeletal manifestation of NAT in 29% of the children.

ISSN:0022-5282    

出版商:OVID    

年代:2003

数据来源: OVID